Aetna electrocochleography coverage update

Coverage and Medical Necessity Criteria

inv-01: Medically Necessary Indications

Aetna considers electrocochleography (ECOG) medically necessary when either of the following applies:

Medically necessary indications: 1) Evaluation of members with symptoms of episodic dizziness (vertigo, imbalance) or tinnitus to rule out endolymphatic hydrops (Meniere's disease) and perilymphatic fistula; OR 2) When performed with auditory brainstem response (ABR) testing of members with profound hearing loss (PTA >= 90 dB HL at 500, 1000, 2000 and 4000 Hz).

From policy medical necessity section

inv-02: Experimental/Investigational (Not Covered)

The following are considered experimental and investigational (not covered):

ECOG and perilymphatic pressure measurement experimental uses: 1) ECOG for routine screening of hearing impairment, and for all other indications not listed as medically necessary (for example, during superior semicircular canal dehiscence repair and canal resurfacing); 2) Intra-operative ECOG for evaluation of cochlear trauma during cochlear implantation and for prediction of preservation of residual acoustic hearing after cochlear implantation; 3) Measurement of perilymphatic pressure in the management of individuals with Meniere's disease or idiopathic sudden sensorineural hearing loss.

Policy lists these as experimental/investigational

inv-03: Evidence-based findings (no insurer criteria specified)

Evidence summary: Studies report that intra-operative ECochG can detect electrophysiological changes during cochlear implant insertion and is feasible in >90% of patients; however, correlation with long-term postoperative hearing preservation is inconsistent across studies, sensitivity and specificity are limited, and techniques and interpretation vary (extra- vs intra-cochlear recordings, stimulus selection, recording windows). Standardization is needed before routine clinical application.

Summary of systematic reviews and cohort studies

inv-04: Documented clinical uses / evidence

Clinical contexts in which ECoG/perilymphatic pressure measurement have documented utility or are described in the literature:

Cochlear implantation monitoring: Intraoperative ECoG (intra- and extracochlear recordings) has been investigated as a real-time monitor during cochlear implant electrode insertion to detect electrophysiological changes and potential cochlear trauma; interpretation may be limited by electrode movement and requires comparison techniques (simultaneous intra- and extracochlear recordings).

See feasibility and mixed outcome correlations in CI studies

Superior semicircular canal dehiscence (SCD/SCDS): ECoG demonstrates elevated SP/AP ratios in affected ears and can serve as a diagnostic adjunct with CT and vestibular testing; intraoperative ECoG often shows SP/AP changes (increase on exposure, decrease after plugging), though intraoperative changes do not consistently predict postoperative audiometric outcomes.SP/AP ratio ~0.34 reported as diagnostic cutoff in one study; mean affected-ear SP/AP reported ~0.52-0.62

Adams et al, Park et al and related studies

Meniere's disease / endolymphatic hydrops:

The policy lists specific ICD-10 codes that are appropriate when ECOG indications are met and also identifies codes that are not covered for the indications in this bulletin. Covered ICD-10 ranges include codes for Meniere's disease (H81.01–H81.09), various vestibular disorders and vertigo (H81.10–H81.13; H81.311–H81.49), labyrinthine fistula (H83.11–H83.19), sensorineural and mixed hearing loss (H90.* series), sudden idiopathic hearing loss (H91.20–H91.23), tinnitus (H93.11–H93.19), and symptom codes for imbalance and dizziness (R26.89, R42).

The bulletin also identifies ICD-10 codes not covered for the indications listed, including S09.91xA–S09.91xS (unspecified injury of ear [cochlear trauma]) and routine screening encounter codes Z01.10 and Z01.110 (encounters for ear/hearing examination without abnormal findings or for follow-up screening).

Within the material reviewed there are no additional explicit exclusion conditions or clinical scenarios stated beyond the ICD-10 not-covered examples. The document summarizes study findings, feasibility, and limitations of ECOG and perilymphatic pressure measurement but does not specify further insurer-level exclusion criteria.

ECoG abnormalities such as an elevated SP/AP ratio are not unique to superior semicircular canal dehiscence. The policy notes that elevated SP/AP ratios have been reported in other inner-ear conditions including Meniere's disease and perilymphatic fistula, and therefore ECoG findings are not specific for canal dehiscence without correlation to imaging and other clinical tests.

This Clinical Policy Bulletin is intended to assist in administering plan benefits and provides a general description of coverage considerations. It does not constitute an offer of coverage, a contract, or medical advice. Providers should verify member eligibility, benefit coverage, and any prior authorization requirements with the plan and remain solely responsible for medical management of patients.

Published reports do not support the use of perilymphatic pressure measurement as a diagnostic tool for Meniere's disease. Multiple studies cited in the bulletin concluded that perilymphatic pressure measurements did not differ significantly between affected and unaffected ears or between patients and normal-hearing subjects, and the technique was considered not useful for evaluation of Meniere's disease.

Systematic reviews and case series show that intraoperative ECochG recordings can be obtained in the majority of patients (>90%), but the ability of intraoperative ECochG changes to accurately predict post-operative hearing loss is limited. Across studies there is notable heterogeneity in definitions of signal disturbance, recording techniques (extra‑ vs intra‑cochlear), and outcome correlations, resulting in limited sensitivity and specificity for prediction of long‑term hearing preservation.

Conflicting findings and limited interpretability of intraoperative ECochG response changes have impeded widespread clinical adoption. Intra‑cochlear electrode movement relative to signal generators complicates interpretation, and investigators have recommended simultaneous extra‑cochlear recordings and attention to phase shifts and harmonic distortions to help distinguish traumatic from non‑traumatic signal changes.

Billing Codes and Diagnostic Thresholds

Covered CPT Codes (if selection criteria met)CPTCovered

92584

Electrocochleography

Other related CPT CodesCPT

69930	Cochlear device implantation, with or without mastoidectomy
70540	Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)
70542	Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; with contrast material(s)
92587	Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)
92588	Evoked otoacoustic emissions; comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)
92650	Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis
92651	Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report
92652	Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report
92653	Auditory evoked potentials; neurodiagnostic, with interpretation and report

Covered ICD-10 Codes (if selection criteria met)ICD-10Covered

H81.01-H81.09	Meniere's disease
H81.10-H81.13	Vestibular disorders (range listed)
H81.311-H81.49	Vertigo
H83.11-H83.19	Labyrinthine fistula
H83.3X1-H83.3X9	Noise effects on inner ear
H90.3	Sensorineural hearing loss, bilateral
H90.41-H90.42	Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side
H90.5	Unspecified sensorineural hearing loss
H90.6-H90.8	Mixed conductive and sensorineural hearing loss
H91.20-H91.23	Sudden idiopathic hearing loss

1–10 of 15

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ICD-10 Codes Not Covered for Indications ListedICD-10Not Covered

S09.91xA-S09.91xS	Unspecified injury of ear [cochlear trauma]
Z01.10	Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]
Z01.110	Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]

Codes mentionedmixed

No codes listed

Covered CPT CodesCPT

No codes listed

inv-18: SP/AP ratio — diagnostic threshold value

SP/AP ratio diagnostic threshold> 35% (SP/AP ratio >35% suggests endolymphatic hydrops)

What it measuresAmplitude ratio of the cochlear hair cell-generated summating potential (SP) to the auditory nerve action potential (AP)

Recording method requiredTranstympanic electrode (fine needle through anesthetized tympanic membrane) placed in contact with cochlear hair cells

inv-19: Profound hearing loss (PTA) — definition threshold

Profound hearing loss (PTA) definitionPure tone average (PTA) of 90 dB HL or greater at 500, 1,000, 2,000 and 4,000 Hz

Prior Authorization, Documentation, and Clinical Actions

Prior Authorization

Prior authorization and benefit verification

Prior authorization and benefit verification: Providers should verify member benefit coverage and any prior authorization requirements with Aetna before performing electrocochleography (ECoG) or perilymphatic pressure measurement. Lack of verification may result in claim denial or member liability.

Verify benefits and prior authorization with the plan prior to service
No specific prior authorization codes or processes are stated in this policy; check payer-specific portals or provider services

Note

No explicit coverage authorization requirements

No explicit coverage authorization requirements in this policy section: The Clinical Policy Bulletin does not state specific prior authorization or pre-authorization requirements for ECoG, intra-operative ECoG, or perilymphatic pressure measurement. However, coverage determinations depend on whether selection criteria in the policy are met.

92584 (Electrocochleography) is covered when medical necessity selection criteria are met

Clinical Background and Evidence Summary

Meniere's disease (endolymphatic hydrops) is characterized by episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness; the disorder has an estimated incidence on the order of a few hundred per million. Trans‑tympanic electrocochleography (ECoG) evaluates inner‑ear physiology by recording the summating potential (SP) and the action potential (AP) and calculating the SP/AP ratio. An elevated SP/AP ratio has been used as an indicator of endolymphatic hydrops, and ECoG may be performed with auditory brainstem response testing to assist identification of wave I in cases of profound hearing loss (PTA ≥ 90 dB HL at 500, 1,000, 2,000 and 4,000 Hz).

inv-04 (supporting evidence overlap): Documented clinical uses / evidence — (also referenced under Coverage Criteria) used here to summarize study findings and contexts

Support and study findings: Selected clinical series and studies report elevated SP/AP ratios in SCD/SCDS, intraoperative SP/AP decreases after canal plugging, feasibility of intra-cochlear ECochG recordings, and mixed correlations between intraoperative ECochG changes and postoperative hearing; these findings overlap with coverage criteria where diagnostic adjunct use for hydrops and use with ABR in profound hearing loss are delineated as medically necessary, while intraoperative monitoring and perilymphatic pressure measurement remain investigational.

Supporting evidence summarized for policy context

Recent literature examining intraoperative ECochG during cochlear implantation highlights technical variability and interpretive challenges. Studies report that electrode movement, recording location, stimulus parameters, and signal analysis (including phase and harmonic content) can all influence intra‑cochlear ECochG responses. Because of these heterogeneous methods and inconsistent outcome correlations, the evidence to date does not provide a standardized, reliable intraoperative ECochG metric for predicting cochlear trauma or long‑term hearing preservation.

Definitions and Key Terms

inv-38: Summating potential/action potential (SP/AP) ratio — definition and diagnostic threshold

DefinitionThe amplitude ratio of the cochlear hair cell-generated summating potential (SP) to the auditory nerve action potential (AP)

Diagnostic threshold> 35% (SP/AP ratio >35% suggests endolymphatic hydrops / Meniere's disease)

Recording requirementRequires electrode placement on or through the tympanic membrane (transtympanic needle electrode)

inv-39: Profound hearing loss — PTA definition

Profound hearing loss (PTA)Pure tone average of 90 dB HL or greater at 500, 1,000, 2,000 and 4,000 Hz

Clinical useECoG performed with ABR testing to help identify wave I in patients with profound SNHL

Policy Dates and Revision History

2023-08-09last_reviewLatest

Policy underwent routine review (Last review recorded).

2001-09-25effective

Policy became effective on this date.

2024-06-13next_review_scheduled

Next routine review scheduled.

OpenPayer

Electrocochleogram and Perilymphatic Pressure Measurement